The seam on the vessels is needed for traumatic dissection, surgical treatment of diseases of the arteries and veins. The most common option is the continuous connection of parts in a circle by the Carrel method. The lateral and mechanical method can also be used. In pediatric practice, nodal sutures are preferred.
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When is Carrel intervention needed?
All operations on the vessels (with the exception of endovascular) provide for the imposition of a vascular suture upon completion. Diseases that may require this technique:
- malformations of the vessels, combined anomalies in the development of the cardiovascular system;
- vascular tumor;
- aneurysm, including traumatic origin;
- , thromboangiitis;
- narrowing of the aorta,;
- , gangrene;
- trauma with partial or complete intersection of the vessel;
- acute, chronic blockage of the lumen of the artery, vein;
- thromboembolism.
Damage to the vessel can occur as a complication during any surgical operation or during diagnostic procedures, which requires suturing of its edges.
Features of the imposition of a vascular suture
There are various techniques and types of sutures, but the main steps for connecting vessels are usually as follows:
- Isolation of the vascular branch from the surrounding tissues.
- Inspection of the wound, soft tissues, localization of nerve plexuses, bones, stop bleeding.
- Preparation for the performance - the imposition of clamps or rubber turnstiles.
- If necessary, resection of the segment, prosthetics.
- Sewing the ends of the vessel.
- Removing the far and then the near clamp (in relation to the direction of blood flow).
- Checking the tightness and patency in the seam area.
In this case, the connection of the edges is carried out from the inner shell outward in order to prevent delamination, especially in atherosclerotic lesions. In the opposite direction, blood clots often form at the suture site. The distance between two stitches should be 2 mm.
If a vein is sutured, then they recede 1 mm from the edge, and 2 mm is needed for an artery, with weak walls, you can increase the indent. The thread is kept taut, the junction is washed with saline with heparin to prevent thrombosis.
Before completing the operation, you need to make sure that there are no clots in the lumen of the vessel. To do this, the clamp is removed for a few seconds and they are cleaned with a blood stream, a heparinized solution is injected and the full integrity of the artery or vein is restored.
Depending on the reason for which the operation is performed, it is necessary to restore the main hemodynamic parameters:
- eliminate the consequences of blood loss in case of injury (introduction of plasma substitutes, blood, erythrocyte mass);
- provide protection against increased activity of the coagulation system with the help of anticoagulants;
- maintain normal and ;
- conduct general strengthening treatment for debilitated patients.
Anesthesia
It should be borne in mind that the imposition of a vascular suture is a technically complex operation, it sometimes takes several hours. The surgeon needs a long time to not only carefully stitch the vessel, but also to prevent the risk of its blocking by a thrombus or cicatricial narrowing in the future.
For this, general anesthesia is most often used. With major reconstructive interventions, anesthesia can be endotracheal (inhalation). The choice of drug for anesthesia is selected taking into account the age of the patient and the location of the vessel. Small vascular defects of the superficial branches are operated on with local anesthetics.
Tools for conducting
The operation may require:
- arterial, aortic, venous clamps;
- scissors, scalpel, tweezers;
- rubber holders;
- catheters for expanding the vessel;
- atraumatic needles in which the thread is soldered.
An important component of vascular surgery is high-quality suture material. It should be smooth, not saturated with blood, have sufficient strength, and not cause inflammation or allergic reactions. Predominantly used prolene, ethylone, mersilene from 3 to 10 conventional numbers. They provide a reliable seam, do not linger when passing through the layers of the wall of an artery or vein, they can be easily tightened.
The needles are chosen curved with a very thin tip and a round body - cutting and stabbing. The diameter of the stabbing part is almost half that of the main part. The channel created by such an instrument prevents postoperative bleeding, leakage of the connection and damage to fragile vessels.
Performance Requirements
Since the invention of the vascular suture, the requirements for its implementation have changed with the advent of new instruments, including microsurgical, special threads. The following conditions are currently required:
- the convergence of the edges of the vessels should not exceed their natural extensibility, since with strong tension the inner layer or the entire wall is torn, which causes thrombosis, bleeding and necrosis;
- it is extremely important that the inner, muscular and outer layers come into contact only with those of the same structure, the penetration of the middle and outer shells into the lumen is unacceptable, since they immediately become a stimulus for the formation of a blood clot;
- when connecting the branches of the artery and vein, it is impossible for them to narrow after the operation or deform;
- the stitches of the seam should not let blood through.
Watch the video on how the vascular suture is performed:
Suturing technique and their types
The side seam is the easiest to perform, followed by a continuous circular seam, and the eversion seam and the connection of different calibers are the most difficult. To determine the technique, surgeons are guided by the clinical situation, vessel diameter, age characteristics, and hemodynamic parameters.
Circular
The circumferential suture is applicable for complete dissection of an artery or vein due to trauma, surgery, aneurysm removal, or in the process of prosthetics. The classic technique is Carrel stitching. The following steps are considered to be the operation algorithm:
- The convergence of the ends to complete docking, but without overstretching.
- Stitching at an equal distance with 3 stitches through all layers, tying the threads into knots.
- Using these stitches to stretch the gap (stitches).
- Create an equilateral triangle.
- Continuous seam between holders.
It is also possible to use two stitches (according to Morozova) with two needles with threads that are tied in the middle. The front wall is sewn together with one, the vessel is turned over and the back wall is connected with a seam. If you need to suture the aorta, a large vein, then first the far segment (back part) is stitched from the side of the inner shell, and then the outer one, but the outer layer is already used.
To bring the ends together, the Polyantsev method is also suitable - two U-shaped seams for turning the edges and twisting stitches between them in a circle. Such a suture can only be applied if there is excess tissue between the vascular segments in the junction zone.
Mechanical
Tantalum clips and Donetsk rings are used for it. With the help of a special apparatus, the edges are connected with a kind of stapler. To do this, the vessel is fixed with clamps and mounted on the staple part, by pressing the lever, the walls of the artery or vein are sutured. This is fast enough, but due to the fact that a large segment needs to be removed from the tissue, the mechanical method is not suitable for deep wounds. They are also not used for different diameters of the connected parts.
Rings of Donetsk are metal circles with spikes along the edges. The vessel is inserted into the ring, and its edge is turned out with tweezers, then put on the spikes. Such a structure is placed in the lumen of the other part and its walls are pierced with spikes. The manipulation is simple, the ring prevents the walls from falling off, the patency is maintained, but at the same time the spikes and metal injure the walls, which is especially dangerous in atherosclerosis and diabetes.
Side
If there is a transverse incision, then it is stitched along the defect with the usual wrapping seam from the far side to the near one. For a stab wound or a small injury, single interrupted sutures or in the form of a P are used. This option can also be used for surgical incision of the lateral surface during the extraction of a thrombus or embolus.
A longitudinal defect is more difficult to sew up. On large branches (from 0.8 cm in diameter), a continuous suture is needed, and for smaller ones, a patch from one's own vein is required.
If sewn without additional expansion with a venous insert, the lumen is significantly reduced, which causes ischemic disorders in the tissue. At the same time, it is important that the size of the installed patch does not allow it to form an aneurysmal protrusion. It disrupts the linearity of blood flow and leads to the formation of blood clots.
In some cases, vascular surgeons, in order to speed up the connection of blood vessels and reduce the duration of the operation in debilitated patients, impose a twisting suture on small vessels. To do this, install a plastic catheter in the lumen. This technique requires a high level of skill.
With different sizes of vessels
Regular seams are not easy to perform, but the situation is aggravated when connecting parts with different calibers. Most often, Carrel is sewn in a circular way with Morozova's modification, and in order to prevent narrowing of the lumen, the following is performed:
- cutting out 2 - 3 flaps to change the direction of the seam and expand its perimeter;
- creating bevelled edges;
- longitudinal dissection of a small vessel.
Watch the video about Carrel's vascular suture:
Features of operations in children
In childhood and adolescence, it is necessary to provide for the growth of an artery or vein. Therefore, the traditional technique of a continuous seam in a circle is not applicable. A continuous U-shaped suture is especially dangerous for the formation of the vascular network; it often becomes an obstacle to the subsequent movement of blood.
The connection of vessels in pediatric surgery is carried out with interrupted sutures. After installing 2 stitches-holders, all layers of the connection are sewn and knots are tied. Their location can be on the same side or on different.
The advantages of this seam include:
- you can fully match the inner layers;
- the risk of narrowing the stitching site is lower than that of continuous ones;
- the vessel changes its lumen during contraction and relaxation;
- there are conditions for growth.
The disadvantages are: lower strength and tightness of the suture, greater blood loss and duration of application.
The need to connect vessels may arise in case of traumatic and surgical injuries, restoration of organ nutrition during shunting, removal of a blood clot.
The choice of the type of vascular suture takes into account the disease, location, caliber of the artery or vein, and the age of the patient. The classic technique is the Carrel method - a circular continuous twisting seam. In children, interrupted sutures should be used. Any of the connections must provide protection against subsequent narrowing and thrombosis.
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The vascular suture is one of the most important stages of reconstructive operations on the vessels, however, very often the imposition of a vascular suture is the main stage, the essence of the reconstructive operation. The success of vascular surgery is largely associated with the development and improvement of the vascular suture technique.
When applying a suture to the vessels, the following basic provisions should be followed.
- An important condition is sufficient mobilization of the vessel, thorough bleeding of the surgical field with temporary clamping of the proximal and distal sections of the vessel.
- The suture is applied using special instruments and atraumatic needles, which ensures minimal trauma to the vessel wall, especially the intima.
- The passage of the thread through the wall of the vessel is facilitated and less traumatic if it is first passed through gauze moistened with petroleum jelly.
- The seam is applied through all layers of the walls of the vessels, their ends to be sewn must touch along the line of seams with their inner shell.
- The suture material should not enter the lumen of the vessel in order to ensure minimal contact with the blood in order to avoid thrombosis.
- The needle is injected approximately 1 mm from the edge of the vessel, the suture stitches are placed at a distance of 1-2 mm from one another.
- With pathologically altered walls (a tendency to eruption of sutures) and suturing large-diameter vessels, more tissue is captured in the suture and the distance between individual stitches is increased.
- The vascular suture must be airtight both along the line of contact of the walls of the vessel, and in the places where the threads pass. This is ensured by sufficient tightening of the seams.
- During suturing, the assistant constantly maintains the thread in tension.
- The tightness control is carried out after suturing by removing the distal clamp.
- In the absence of significant bleeding, the central clamp is removed and a swab moistened with warm saline is applied to the vessel for several minutes in order to stop bleeding along the suture line.
- Prevention of thrombosis in the vessel during its temporary clamping consists in the introduction of heparin locally into the adducting and efferent segments of the vessel or into the general bloodstream, into the vein 5-10 minutes before the vessel is clamped. We prefer in most reconstructive operations, especially for occlusive diseases, to inject heparin into a vein (5000 IU, or 50 mg) and at the same time locally (2500 IU, or 25 mg, heparin dissolved in 200 ml of saline).
- With prolonged clamping of the vessel, it is advisable to slightly open the distal and proximal clamps before applying the last sutures in order to remove possibly formed blood clots.
- After suturing and releasing the artery from clamps or tourniquets, one should make sure that there is a pulsation of the peripheral part of the vessel.
Circular vascular suture.
Of the many ways of applying a vascular suture, developed mainly during the first half of the 20th century. (N. A. Dobrovolskaya, 1912; G. M. Solovyov, 1955; Marphy, 1897; Carrel, 1902; Payr, 1904; Danis, 1912, etc.), currently, various modifications of the Carrel seam are most often used.
The Carrel suture technique is as follows (Fig. 3, a). Both ends of the vessel are stitched through all layers at an equal distance from each other with three guides, situational sutures-holders. The ends of the vessel are brought together and the threads are tied. When stretched by the ends of the threads, the artery acquires a triangular shape, which ensures that the opposite wall is not captured by the needle when a continuous continuous suture is applied between the holders.
Rice. 3. Diagrams of the circular vascular suture of the artery:
a- seam according to Carrel;
b- simplified technique of circular vascular suture;
c - a seam from the inside of the lumen of the rear wall of a large-caliber vessel;
G- eversion mattress, continuous and nodal sutures
A. I. Morozova (1909) suggested using two threads instead of three situational sutures, and A. A. Polyantsev (1945) used U-shaped situational sutures to bring the ends of the vessels together, which twist the edges of the vessel.
At present, this simplified technique of vascular suture is usually used: a simple twist suture is applied to the posterior wall of the vessel, after which the clamps together with the vessel are rotated by 180° and the other semicircle of the vessel is sutured (Fig. 3, b).
It is more convenient to apply such a suture with a thread equipped with two atraumatic needles. When suturing large vessels, such as the aorta, in the depth of the wound, we often sutured the posterior semicircle of the vessel from the inner surface (Fig. 3, in).
The mattress eversion vascular suture has not lost its practical significance - nodal and continuous (Fig. 3, G). While providing a good seal, it can narrow the vessel along the suture line, and a continuous mattress suture prevents vessel growth and lumen enlargement (Holman and Nahl, 1954). We apply mattress sutures, usually interrupted, on the altered vascular wall with a tendency to eruption of the sutures and as additional sutures in order to stop bleeding along the suture line.
With a significant discrepancy between the diameter of the anastomosed vessels, a typical or simplified Carrel suture is also used with a dissection of the vessel wall of a smaller diameter for better adaptation of the edges, as shown in Fig. four, a.
In order to prevent narrowing of the lumen of a small-diameter vessel along the suture line, it is advisable to use the so-called beveled end-to-end anastomosis, obliquely cutting off the ends of the vessels to be sutured (Fig. 4, b). In some cases, the method of "patch" from a vein can be applied (Fig. 4, in).
Various modifications of the invagination suture - the methods of Solovyov, Marphy, Denis and others - fig. 4, g- currently practically not used.
In reconstructive surgery of the arteries, vascular sutures are usually applied manually. In order to simplify the suture technique, to avoid possible narrowing of the lumen of the vessel and to reduce the time of the operation, vascular stapling devices for applying a mechanical tantalum suture and special rings were proposed (D. A. Donetsk, 1956).
The NIIEKhAI vascular stapling apparatus was developed by a group of engineers and doctors (V. F. Gudov, N. P. Petrova, P. I. Androsov and others) in 1946-1950. The ends of the vessel are disassembled and fixed on the bushings of the staple and thrust parts of the apparatus, the latter are connected and, using a special lever, the walls of the vessel are stitched with tantalum clips (Fig. 4, e).
The use of a mechanical suture is possible with a sufficiently wide mobilization of the ends of the vessel - at least 1.5-2 cm - and the presence of a slightly changed, elastic vascular wall. It is inconvenient to use the device in a deep wound. Therefore, the scope of the mechanical suture is generally limited in the treatment of vascular injuries.
Rings of Donetsk are not currently used, and the industry does not produce them.
Lateral vascular suture. Tactics may be different when suturing a transverse and longitudinal vessel defect.
For suturing a transverse defect, which occupies a significant part of the circumference of the vessel, usually a continuous twisting suture is used through all layers of the vascular wall (Fig. 5). It is more convenient to sew on yourself - towards the corner of the wound adjacent to the surgeon. Sutures are placed in the transverse direction, which reduces the possibility of narrowing the lumen of the artery. For suturing wounds of small size, stab wounds, single interrupted and U-shaped sutures are also used. However, it is impractical to apply an eversible U-shaped suture to small-caliber vessels, since when an excess amount of tissue is captured, a kink of the vessel and a narrowing of its lumen can be observed.
Transverse arteriotomy followed by lateral suture remains the method of choice for opening peripheral vessels for embolism and thrombectomy.
The choice of method for suturing a longitudinal lateral defect in the artery wall is primarily determined by the caliber of the vessels. Arteries larger than 8 mm in diameter are usually closed with a continuous twist suture. Longitudinal wounds of arteries of small and medium caliber are usually closed by the method of lateral plasty with a patch from a vein
Rice. 4. Schemes various methods circular vascular suture:
a- a suture with a dissection of the vessel wall of a smaller diameter, used when the diameters of the anastomosed vessels do not match;
b, c- beveled end-to-end suture and with a venous patch, preventing narrowing of the lumen of a small-diameter vessel along the suture line;
With- Murphy invagination suture;
d- stapling of the vessel by the NIIEHAI apparatus (/ - disassembly of the vessel; 2 - the vessel is disassembled and fixed on the bushings of the staple and thrust parts of the apparatus; 3 - vessel after flashing with tantalum staples and seam diagram)
It is not advisable to use the main trunk of the great saphenous femoral vein for patching, given the possibility of using the vein in the future for arterial bypass grafting. We use lateral branches of the great saphenous vein for patching, as well as a segment of the marginal vein resected above the medial malleolus.
The patch is usually sewn with two threads, using them also as holders. When suturing the venous flap, it is advisable to stick the needle in the direction of the artery - vein. This avoids retraction of the vein adventitia and tucking of its edges. The transverse size of the patch should be such that there is no narrowing of the lumen and at the same time there is no aneurysmal expansion at the site of the patch. In the latter case, laminar blood flow is disturbed, turbulence occurs, which creates favorable conditions for the formation of a parietal thrombus.
Rice. 5. Scheme of the side seam of the vessel
Rice. 6. Methods for preventing narrowing of the lumen of vessels of medium and small diameters when suturing a longitudinal wound of the vessel:
a- a simple suture causes narrowing of the vessel;
b- lateral venoplasty with a patch;
in- incorrectly performed lateral venoplasty - aneurysmal expansion at the patch site;
G- Adequate wages;
d- lateral angioplasty using the lateral branch of the vessel;
e- a suture on the catheter or on a special dilator probe inserted into the lumen of the vessel
With a high operating technique, it is allowed to impose a direct longitudinal lateral suture on vessels of medium and even small caliber (Sappon, 1963) according to special indications, for example, with a high operational risk in debilitated patients to reduce the duration of the operation, with the risk of wound suppuration. In such cases, it is advisable to apply a twisting suture on a plastic catheter inserted into the lumen of the vessel in order to reduce the possibility of its narrowing.
The technique of the vascular suture when applying side-to-side and end-to-side lateral anastomoses is generally the same as for end-to-end suture. Previously, surgeons were reserved about this type of anastomoses, but now they are widely used in vascular reconstructive surgery, especially in bypass grafting.
The use of a vascular suture as the main method of restoring the main blood flow is limited to the treatment of traumatic or surgical vascular injuries, some forms of aneurysms, as well as segmental obliterations, deformities, and kinks of vessels limited in length (Fig. 7).
The imposition of a vascular suture is far from a simple intervention. In this case, the following main mistakes and complications.
The narrowing of the lumen of the vessel along the suture line is more often due to the capture of an excess amount of tissue. In this case, with a circular end-end and transverse lateral suture, it is advisable to excise the edges of the vessel along the suture line and apply a new end-to-end anastomosis. With a longitudinal lateral suture, an increase in the lumen of the vessel is achieved by a lateral venoplasty patch.
Bleeding along the suture line is usually due to insufficient tightening of the thread when suturing, weakness of the vascular wall during thinning, inflammation and other pathological changes in it. To stop bleeding, warm wet swabs, hemostatic gauze are applied to the vessel, single, U-shaped and interrupted sutures are applied, medical glue (MK-2, MK-6) is used. With the weakness of the vascular wall, the suture line can be strengthened with a strip of fascia like a cuff. To fix it to the vessel and better seal, we use MK-6 glue.
Thrombosis of the vessel after suturing can be due to various reasons: errors in the suturing technique (narrowing of the vessel lumen along the suture line, tucking of the intima of the peripheral end of the vessel, if it is not captured in the suture or detached and not fixed with separate sutures, crushed areas of the vessel are not excised ), temporary clamping of the vessel. To remove a thrombus, depending on the specific situation, the artery is cut along the suture line or distal to it.
In case of doubt regarding the patency of the distal vascular bed, a revision of the distal vessels using balloon catheters, arteriography on the operating table are indicated.
Rice. Fig. 7. Schemes of vessel reconstruction using a circular or lateral vascular suture after resection of the altered segment (a) or wall (b) of the artery
Mandatory requirements for the connection of vessels are the tightness of the seam and the absence of a pronounced narrowing in the area of the anastomosis. This is achieved by bleeding the surgical field, careful comparison of the inner surfaces of the vessels, and minimal contact of the suture material with blood.
Lateral vascular suture
Indications: traumatic injury of less than a third of the circumference of the vessel, surgical treatment of aneurysms of vessels, deobliterating stage on the vessels.
Technique. The vessel is isolated from the paravasal tissues, clamps are applied, designed for vessels above and below the damage. After cutting off the damaged edges of the vessel with an atraumatic needle, a continuous continuous suture is applied through all layers of the vessel wall (transversely). For suturing small wounds, interrupted U-shaped sutures are used; for large defects, a patch of autovein or synthetic material is sewn into the vessel wall.
Bleeding in the suture area is stopped by applying warm tampons, a hemostatic sponge, applying single U-shaped, interrupted sutures. reinforcing the suture line with medical glue or a fascia flap.
Circular vascular suture
Circular vascular suture of Carrel:
the edges of the vessel are brought together by sutures-holders; stitching of vessels between the sutures-holders; suturing around the circumference of the vessel
Circular vascular sutures:
a - Polyantsev and Gorsley; b - Briana-Zhaboulet
Indications: significant damage to the vessel, its complete intersection, the stage of reconstructive vascular operations.
Carrel suture technique. Allocate the ends of the vessel, apply clamps above and below the intended seam. The ends of the vessel are brought together and stitched through all layers with three nodal guide sutures-holders located at the same distance between them. In the interval between them, the edges of the vessel are sewn with atraumatic needles with a continuous continuous seam. The needle is injected approximately 1 mm from the edge of the vessel wall to be sutured, the distance between the stitches of the suture should be 1-2 mm. At the same time, they should not be allowed to relax. Having finished sewing up one side of the seam, the main thread is tied to the thread of the seam-holder, and the other two sides are similarly sutured. First, the clamp is removed from the peripheral end of the vessel, and then from the central one.
Polyantsev and Gorsley's seam technique. A feature of the technique of this seam is the use of mattress U-shaped seams-holders, which turn the inner shell of the vessels inside out. Between the sutures-holders, the edges of the vessels are sewn together with atraumatic needles with a continuous continuous seam, with a distance of 1 mm between the stitches.
Briand-Jaboulet seam technique. A feature of the technique of this seam is the use of mattress U-shaped seams-holders that turn the inner shell of the vessels inside out. Between these sutures, the edges of the vessels are sutured with atraumatic needles with a mattress interrupted or continuous suture.
Medicine and Veterinary
In relation to the circumference of the vessel, the seams are circular and lateral. A circular suture is applied with a complete rupture or violation of the integrity of the vessel over 2 3 circumferences. The lateral suture is applied with the longitudinal direction of the wound of the vessel wall or with a transverse wound not exceeding 1 3 of the circumference. Disadvantages: the suture covers the vessel with an unyielding ring: the suture material goes into the lumen of the vessel; Seam tightness is not always guaranteed.
Vascular suture. Indications, technique, complications.
In relation to the circumference of the vessel, the seams are circular and lateral. A circular suture is applied with a complete rupture or violation of the integrity of the vessel over 2/3 of the circumference. The lateral suture is applied with the longitudinal direction of the wound of the vessel wall or with a transverse wound not exceeding 1/3 of the circumference.
Circular seams. depending on the technique of anastomosis formation, they are divided into 4 groups:
- upholstery (Carrel. Morozov) - the anastomosis between the segments of the vessels is created by a continuous circumferential suture. Disadvantages: the suture covers the vessel with an unyielding ring: the suture material goes into the lumen of the vessel; Seam tightness is not always guaranteed.
- eversion (Sapozhnkova. Braytseva. Polyantseva) - provide a tighter contact of the inner shells of the sutured segments of the vessels.
- Invasive(Soloviev) - immersion of the peripheral segment into the central segment of the vessel with the formation of a cuff along the connection line. These sutures can only be used for anastomosis of vessels of different diameters, otherwise narrowing occurs along the suture line.
- Mechanical - provide a good comparison of the walls of the vessels and sufficient tightness of the anastomosis. The use of a hardware suture allows a surgeon who does not have sufficient experience in angiosurgery to sew the vessel well. Disadvantages: it is impossible to use in deep wounds and cavities, it is necessary to mobilize segments of the vessel for at least 4-5 cm. (In practice, they are used very rarely).
Indications
- vascular injury;
- arterial and arteriovenous aneurysms;
- creation of intervascular anastomoses;
- plastic and reconstructive operations on the main vessels in atherosclerosis and endarteritis.
Overlay technique
1. Surround vascular suture
After mobilization and exclusion from the blood flow of the proximal and distal segments of the vessel, their ends are sutured through all layers with three guide sutures - holders, located at an equal distance from each other.
As sutures of the holders, U shaped sutures or simple nodal sutures are used, which should provide a slight inversion of the walls of the artery by the intima to accurately match the edges of the vessel. The threads from the seams of the holders are not cut off. When applying a vascular suture, the sutures of the holder are stretched so that the line of contact between the segments of the vessels has the shape of a triangle. In the intervals between the seams with holders, the adjacent edges of the vessel are sewn with a continuous twisting seam. Stitches of a continuous seam are carried out at a distance of 1 mm from each other through all layers of the vessel around the entire circumference so that after tightening the seams, the threads do not protrude into its lumen. A continuous suture begins to be applied to the part of the anastomosis closest to the surgeon. The first stitch should be at the seam of the holder. The stitch distance from the edge of the vessel and from stitch to stitch should be 0.7 0.8 mm. When applying a continuous seam, it is advisable not to tighten each sewn stitch, but to first apply an “open” seam without tightening the thread, followed by tightening the loops. This technique allows, before stitching the entire semicircle of the anastomosis, to carry out visual control of its lumen and thereby reduce the risk of accidental capture of the opposite vessel wall into the suture. Completing the continuous twisting seam of one semicircle of the anastomosis, the last stitch is applied close to the second seam of the holder and the thread is tied to one of the threads of the seam of the holder. Further, pulling the handles by the sutures, the vessel is rotated, opening the opposite wall of the fistula for suturing, and all semicircles of the vascular anastomosis are formed. After that, the threads of the suture material are cut off between the seams holders.
2. Eversion U shaped vascular sutures
In case of suturing a transverse wound, a continuous eversion U-shaped suture is applied to the vessel. An eversible U shaped vascular suture is used to accurately match the edges of the vessel. To stitch the posterior wall of the proximal and distal segments of the vessel, first, an interrupted mattress suture is applied to the corner without tightening the stitches. Only after stitching the entire back wall, they bring the edges of the vessel together, simultaneously pulling the threads, and thereby achieve the tightness of the seam line. Tie the first knotted suture. A thread of a continuous seam is connected with it. The anterior wall is sutured with one continuous mattress suture.
3.Hardware seam
The essence of the seam lies in the fact that at the same time small tantalum clips are applied to both walls of the vessels, turned inside out on special bushings of the apparatus, tightly adjacent to each other.
Complications
- The narrowing of the lumen of the vessel along the suture line is more often due to the capture of an excess amount of tissue.
- Bleeding along the suture line is usually due to insufficient tightening of the thread when suturing, weakness of the vascular wall during thinning, inflammation and other pathological changes in it.
- Thrombosis of the vessel after suturing can be due to various reasons: errors in the suturing technique (narrowing of the vessel lumen along the suture line, tucking of the intima of the peripheral end of the vessel, if it is not captured in the suture or detached and not fixed with separate sutures, crushed areas of the vessel are not excised) , temporary clamping of the vessel.
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| 12 Laboratory work No. 13 Studying the law of conservation of energy using Maxwell's pendulum 1. Purpose of the work Studying the law of conservation of energy using the example of the movement of Maxwell's pendulum. The disk of the pendulum is directly the disk itself and replaceable rings that are fixed on the disk. When the pendulum is released, the disk begins to move: translational down and rotational around its axis of symmetry. | |||
| 37945. | TILT PENDULUM | 252KB | |
| Study of the force of rolling friction. Determination of the coefficient of rolling friction. From the side of the surface, the friction force FTR acts on the body. A body slides over a surface at a speed that is acted upon by a friction force that negative work As a result, the total mechanical energy of the system decreases. | |||
| 37946. | Studying the law of conservation of angular momentum using a gyroscope and determining the rate of its precession | 695KB | |
| 12 Laboratory work No. 15 Studying the law of conservation of angular momentum using a gyroscope and determining the speed of its precession 1. Purpose of the work Studying the gyroscopic effect and the law of conservation of angular momentum using a gyroscope. Determination of the gyroscope precession speed measurement of the angular velocity of rotation of the gyroscope flywheel and the moment of inertia of the gyroscope. The validity of this law can be checked using a gyroscope. | |||
| 37947. | Determination of the Poisson's ratio of air by the adiabatic method | 445KB | |
| 1 Determination of the Poisson's ratio of air by the method of adiabatic expansion: Guidelines for laboratory work No. 16 on the course of general physics Ufimsk. The work determines the Poisson's ratio of air by the adiabatic expansion method based on measuring the gas pressure in the vessel after successively occurring processes of its adiabatic expansion and isochoric heating. | |||
Straight - directly along the projection line
Roundabout - stepping back from the projection line
Indications for vascular exposure: vascular damage. The goal is to stop bleeding and restore the main blood flow.
Stop bleeding
1.Temporary:
a) finger pressure - it is important to know the projection of the vascular formation (clamping above the bleeding site - bleeding does not stop, because it is necessary to clamp at 2 points - above and below the bleeding site) the blood flow will be carried out through collaterals
b) digital pressure is replaced by a pressure bandage or tourniquet
c) giving the limb a certain position in the joints (flexion)
d) temporary ligation of vessels
- in the wound - large vessels, only at the time of transportation. their final dressing is not permissible (their branches are tied up), because can lead to limb amputation, with the exception of the paired arteries of the lower leg and forearm.
- Throughout (outside the wound) - when it is impossible to tie off the artery in the wound or it is not in the wound (for example, the gluteal artery, if the gluteal muscle is damaged, the internal iliac artery is ligated)
You can not bandage temporarily when there is pollution, or the wound is extensive.
Temporary vascular prosthetics (the prosthesis lasts up to a day or more) - while maintaining the main blood flow. As prostheses - plastic tubes from the blood transfusion system (they are treated from the inside with silicone - their wall is not wetted and prevents the process of thrombosis). There are also specially made temporary prostheses.
- 2. Constant
Restoration of a damaged vessel - suturing
- Side seam - if the damage is tangential and affects more than 1/3 of the circumference and if the edges of the vessel have an even cut and are not broken, not crushed
- Continuous twisting - if the damage is more than 1/3 or 1/2 of the circumference or the vessel is completely damaged:
- Manual
- With a vasoconstrictor
- Excision of the site and replacement with a graft - if the destruction of the vessel is significant and exceeds 3-4 cm in length
vascular injury.
1.obliterating vascular disease- atherosclerotic obstruction of blood vessels, cat. usually large vessels (of the lower extremities) are affected; narrowings gradually appear in these zones (popliteal, femoral, iliac aa.), aortic bifurcation, and a decrease in blood flow below the injury site gradually begins. included on the set. collateral time, there is a stage of compensation, then collaterals also begin to turn off as obstruction develops, ischemia increases, pain is not only when walking - tension ischemia, but also at rest, then trophic ulcers appear and then amputation.
recovery: 1) resection of the damaged obliterated area and its replacement with a transplant-art. or natural.
2) the same graft can be sutured above and below the site of occlusion and the master is resumed on this graft. blood flow - roundabout character
3) dissection over the area of occlusion of the vessel and hemming of the patch - from synthetic. or natural. materials.
atherosclerotic plaques are not removed, but they are dissected and partially restored with a lateral patch.
2. thrombosis is an acute pathology, more often in the elderly. in the next 1.5-2 hours - thrombectomy, otherwise amputation.
Roerish syndrome - an atherosclerotic plaque in the bifurcation of the abdominal aorta, leading to ischemia of both lower extremities. The bifurcation prosthesis is placed above the aortic occlusion and below into the iliac vessels.
thrombectomy - earlier they used tubes for suctioning a blood clot, tools in the form of grips. Currently, Foranti probes (balloon) are used - long catheters when inserted into it skylight k-n liquid (phys. solution, novocaine), a rubber balloon is inflated at the tip, and the blood clot is removed from it. After removal, the surgeon checks the similarity of the artery, removing the tourniquet for a short time and receiving a stream of blood, and stitching is performed.
3. embolism - people suffering from rnvmatism,
4. Vascular aneurysm:1) true against the background of degenerative changes - atherosclerosis.
2) false consequences of injuries
complications: - rupture
delamination
conditions for the occurrence of false aneurysms:
1) the vessel should be located deep in a well-developed muscle mass
2) there must be a wound, the wound channel is narrow
3) the wound of the artery must be tangent.
5. vascular malformations
Aneurysms
Congenital narrowing (coartation of the aorta) of blood vessels
Abnormal tortuosity of the common carotid artery
6. Arteriovenous fistulas
Congenital
Acquired - the consequences of injuries, the injuring object passes at a fast speed between the main arteries and the vein, touches the wall of both and bleeding from the artery begins and immediately the blood is discharged into the vein, after a while a stable anastomosis is formed, the blood does not reach the distal part of the limb - steal syndrome , not only local hemodynamics suffer, but also central - overload of the left ventricle
7. Vessel exposures for diagnostic purposes.
During cardiac surgery. Before these operations, the heart is examined:
Invasive
Non-invasive - little informative.
Invasive: the essence lies in probing the cavities of the heart, if we probe the right half of the heart, the right atrium, the right ventricle - the probe is passed through the veins (v. Basilica) of the upper half of the body. If we examine the left half - then through the large arterial vessels - through the femoral or deep artery of the thigh.
8. Administration of drugs
If we want to achieve a rapid high concentration of a substance, we inject it into a vein. Sometimes intra-arterial administration is used: in cases where a high concentration needs to be created locally in some part of the body medicinal product, which is unacceptable in the general bloodstream - is used in the treatment of tumors, in the treatment of severe suppurative processes.
Directions of vascular surgery
- Microvascular surgery - surgery on vessels of small diameter (less than 2-3 mm). Special surgical equipment is required: instruments, suture material, optical magnification - reflaction of the hand (torn off) and even the torn off distal phalanx can be sutured.
- Endovascular surgery.
Required:
A) with local occlusion of the artery by atherosclerotic plaques;
B) for the treatment of false aneurysm
C) with congenital pathology - non-closure of the ductus botulinum
D) atrial septal defect
Restoration of the vessel can be done with the help of tenting. Stents on the conductor - to the zone of occlusion. At the beginning, the atherosclerotic plaque is crushed with a high-pressure balloon probe, then an inactivated stent is inserted, then it opens with a balloon probe, fills the restored part of the artery and holds it in place, preventing the re-development of occlusion.
Vascular suture
- According to the execution method: 1. Manual
2. Mechanical - with the help of a suture device - small tantalum staples act as a suture material.
Requirements for a vascular suture:
1) Durable, withstand intra-arterial pressure and pulse wave transmission
2) Tight and hemostatic
3) Should not narrow the lumen of the vessel
4) When applying, it is important to achieve a comparison of the intima of the central and peripheral ends of the sutured vessel. If this is not observed, then the middle and even outer membranes will come into contact with the blood flow, and they contain thrombogenic factors, as a result, thrombosis may develop.
5) The threads should not go into the lumen of the vessel - at present, smooth and wettable synthetic threads are used, on which blood clots are not deposited - their contact with the blood stream is possible.
Mechanical vascular suture
It is performed using a vasoconstrictor, the cat is disassembled into 2 parts:
Central and staple.
For each vessel, a sleeve of a certain diameter is selected and the ends of the vessel to be sutured are everted over it, then both halves of the apparatus with the disassembled vessels are brought into contact again and stitching is performed. The suture material is miniature tantalum staples.
Main advantage - speed of stitching, this is especially true when ischemia is critical.
Flaws: not in all cases can be applied:
1) To apply a mechanical suture requires significant separation, separation of the vessel from the surrounding tissues, in order to impose a vasoconstrictor. When applying a manual suture, the separation from the surrounding tissues will be less.
2) Short vessels cannot be sutured with a vasoconstrictor, because the device will not fit.
3) Do not apply to vessels altered by atherosclerotic changes. These vessels cannot withstand eversion, their wall has lost its former elasticity, and when everted, they can collapse.
4) There is no vascular suture machine that could suture vessels with a diameter of less than 1.3 mm (only manual suture is used)
Hand seam
Classification:
1) Edge
2) Invagination - the vessel wall is connected from the central and peripheral ends and the anastomoses are still sutured to the side wall of the central end of the vessel, and invagination of the central end into the peripheral occurs. Such seams are used extremely rarely, because. cause significant narrowing of the lumen. It was used when the suture material was not perfect, because. in this form, the suture material does not come into contact with the blood stream.
Edge seams - the ends of the connecting vessel are brought closer to each other with the help of three fixation sutures at equal distances. With this option, it is important to observe the comparison of the intima so that the blood flow does not come into contact with the middle and outer shells. The surgeon then makes sutures. the assistant stretches the sutures-holders, and the surgeon between them imposes 2 types of sutures:
A) continuous twining
B) separate nodal sutures
The choice of a seam between the sutures-holders, knotted or twisted, will depend primarily on the diameter of the vessel to be sutured.
Considering that the twisting seam narrows the lumen of the vessel to a greater extent, it is used only on vessels of large diameter.
On vessels of small diameter, it is better to use separate interrupted sutures.
Always use separate interrupted sutures between the sutures-holders when dealing with a growing organism, in pediatric surgery, because. the twisting anastomosis will not grow, we will get a rigid ring, the cat will not grow along with the vessel, the vessel will grow and there will be a place of narrowing.
Modern techniques do not involve the imposition of three fixation sutures, but, as a rule, use two fixation sutures, they can be separate nodal, U-shaped, depending on the diameter of the vessel.
When vascular formations are destroyed over a considerable length, more than 3-4 cm, then it is not possible to simply match the ends due to the tension factor. If we do this, the tension will be large, then the threads can cut through the walls of the vessel or end up with thrombosis or severe bleeding. Therefore, we resort to plastic vessels.
Types of plastic replacement of vessels:
1.autoplasty- use the material of their own body - their own veins, arteries.
Vienna- v.saphena magna, veins located in the subcutaneous adipose tissue. - v.saphena magna after obligatory turning over (because it has valves) is sewn into the defect set of large vessel. v.saphena magna can be replaced - femoral, popliteal, brachial arteries.
arteries- large branches extending from the main vessels: the deep femoral artery. According to its diameter, it can replace a defect in the femoral, popliteal or brachial arteries. If we replace the arteries, the cat has the diameter of the arteries of the forearm or the arteries of the lower leg, then a. epigastric inferior.
Results of autoplasty: the best, but autografts can not always be used. Not always used v.saphena magna:
Because we can face vyricose expansion of this vein
Loose type of structure, when it goes not with one trunk, but with 5-6 trunks of a smaller diameter.
a. profunda femori is not always used, namely in the presence of atherosclerotic changes
in all these cases you can use -
2.Alloplasty- within the same species - they are taken from the corpses of young people, the cat died from an injury and does not have a history of diseases - hepatitis, AIDS, syphilis, etc. in young people, because they do not have pronounced atherosclerotic changes.
Allografts cannot be transplanted immediately, because the intima of the vessel may immediately die, it will collapse, exfoliate, wrap, resulting in thrombosis. To avoid this, it is necessary to reduce the antigenic properties of the allograft by various kinds processing.
Types of processing:
1) Physical - verification - drying of the allograft in vacuum at liquid nitrogen temperature (-190 0). Getting into such conditions, the graft loses water, sublimating it goes into the external space and the graft dries up - it becomes dense, rigid, incompressible, it is sealed with a sterile ampoule and stored for a long time at normal temperature.
Before use for surgical intervention, it is returned to the water, placed in a physical. solution for 15-20 minutes, it absorbs water again and returns its properties.
2) Chemical - they use substances that cause rough structural changes in the graft wall - protein denaturation and species specificity decreases. These are weak solutions of alcohol, formalin, etc.
3) complex biochemical - the composition of the preservative includes not only the preservative substances themselves, but also other auxiliary ones, such as anticoagulants or even proteolytic enzymes, which are designed to partially remove the protein.
Allografts cannot take root, they are encapsulated both outside and inside by the body's own tissues, the cat gradually begins to dissolve this transplant, gradually replacing it with its own tissues.
- 3. Xenoplasty- not used, too pronounced antigenic properties.
- 4. Combined plastic
- 5. Prosthetics - artificially made prostheses are used - on the largest vessels - aorta, iliac, sleepy. It is not used on the arteries of the limb, because. high percentage of thrombosis.
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